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2020/02/18 L.C. Paving & Sealing, Inc. Certificate of Liability Insurance (10) A�" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 10/27/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT JANA CLARK NAME: HARTLEY CYLKE PACIFIC-#0574253 aCC Ext: (619)295-5155 A/XC,No): (619)291-0912 INSURANCE SERVICES,INC. E-MAIL ( @p ana he acinsurance.com ADDRESS: 2747 UNIVERSITY AVENUE INSURER(S)AFFORDING COVERAGE NAIC# SAN DIEGO CA 92104-4068 INSURERA: UNITED SPECIALTY INSURANCE CO. INSURED INSURERB: WATFORD INSURANCE COMPANY 25585 L.C.Paving&Sealing,Inc. INSURER C: TOPA INSURANCE COMPANY 620 Alpine Way INSURER D: PALOMAR SPECIALTY INSURANCE CO INSURER E: CLEAR SPRING PROPERTY&CASUALTY COMPANY 15563 Escondido CA 92029 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2091566409 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCEADDLSUBR POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE FX OCCUR PREM SES Ea oNcE ante $ 50,000 MED EXP(Any one person) $ 5,000 A Y Y ATN2035914 02/18/2020 02/18/2021 PERSONAL&ADV INJURY $ 1,000,000 MOTHER LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANYAUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED Y Y WIC100396400 02/18/2020 02/18/2021 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY /� AUTOS ONLY Per accident Medical payments $ 5,000 UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 C X EXCESS LAB CLAIMS-MADE Y Y XL0020024203 02/18/2020 02/18/2021 AGGREGATE $ 4,000,000 DED I I RETENTION $ $ WORKERS COMPENSATION X1 PER STATUTE ERH AND EMPLOYERS'LIABILITY Y/N 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ E OFFICER/MEMBER EXCLUDED? ❑ N/A Y CSWC00024401 09/12/2020 09/12/2021 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ INLAND MARINE D IMFLP20202100300 02/18/2020 02/18/2021 RENTED/LEASED EQP $100,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) *10 day notice of cancellation for non-payment of premium shall apply.*30 days written notice of cancellation for all other reasons. **City of Menifee and its officers,employees,agents,and authorized volunteers shall be named Additional Insured on a Primary and Non-Contributory basis.A Waiver of Subrogation applies as required by written contract. RE:CIP 20-12 ADAMS AVENUE STREET IMPROVEMENTS PHASE 2 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Menifee and its officers,employees,agents,and authorized ACCORDANCE WITH THE POLICY PROVISIONS. volunteers AUTHORIZED REPRESENTATIVE 29844 Haun Road Menifee CA 92586 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2.50 % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION Any Person or Organization for which the insured has agreed by written contract executed prior to loss to furnish this waiver. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 9/12/2020 12:01 AM Policy No. CS-WC-000244-01 Endorsement No. 1 Insured L.C. Paving &Sealing, Inc Premium $2,625 Insurance Company Clear Spring Property and Casualty Company Countersigned by ©1998 by the Workers'Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual © 1999. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 06 (Ed. 8-84) PREMIUM DISCOUNT ENDORSEMENT The premium for this policy and the policies, if any, listed in Item 3 of the Schedule may be eligible for a discount. This endorsement shows your estimated discount in Items 1 or 2 of the Schedule. The final calculation of premium discount will be determined by our manuals and your premium basis as determined by audit. Premium subject to retrospective rating is not subject to premium discount. SCHEDULE 1. STATE ESTIMATED ELIGIBLE PREMIUM $116,878 FIRST NEXT NEXT $5,000 $95,000 $400,000 BALANCE CA $5,000 $100,000 $500,000 0.0% 10.9% 12.6% 14.4% 2. AVERAGE PERCENTAGE DISCOUNT: 10.796034% 3. OTHER POLICIES: 4. If there are no entries in Items 1, 2 and 3 of the Schedule, see the Premium Discount Endorsement attached to your policy number: This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 9/12/2020 Policy No. CS-WC-000244-01 Endorsement 1 Insured L.C. Paving&Sealing, Inc Premium $2,625 Insurance Company Countersigned by Clear Spring Property and Casualty Company WC 00 04 06 (Ed. 8-84) ©1983 National Council on Compensation Insurance,Inc.